Diagnosis

Suprasyndesmotic lesion, proximal fibular lesion (Maisonneuve) (AO/OTA 33C3) 

These fractures occur with the foot in pronation when an external rotation force applied. The first injury is a failure of the medial side either with a deltoid ligament rupture, or medial malleolar fracture. This frees the talus to move anteriorly as it rotates externally. The fibula is caused to rotate resulting in failure of the anterior syndesmotic ligament and then of the interosseous ligament. Finally the fibula fractures proximally, usually by rotation. This is a very unstable injury that always needs at least one, or better two, positioning screws.

These fractures are classified as AO/OTA 44C3 fractures, and correspond to pronation-eversion fractures in the Lauge-Hansen classification. 

Complete radiological evaluation (AP, lateral and AP with internal rotation) is crucial for correct classification and decision making.

Options
1. Without shortening, without Volkmann's (AO/OTA 44C3.1) 
2. With shortening, without Volkmann's (AO/OTA 44C3.2) 
3. With medial lesion, with Volkmann's lesion (AO/OTA 44C3.3) 

1. Without shortening, without Volkmann's (AO/OTA 44C3.1) 

Without shortening, without Volkmann's (AO/OTA 44C3.1)

Without shortening, without Volkmann's (AO/OTA 44C3.1)

If there is a medial injury (deltoid rupture or malleolar fracture) and a proximal fibular injury, but without significant shortening or a Volkmann's fragment, this is classified as an AO/OTA 44C3.1 fracture.

The anterior and interosseous syndesmotic ligaments are always disrupted. The anterior ligament may fail as a ligamentous rupture, or an avulsion fracture, of the anterior syndesmotic ligament, either at its fibular (Le Fort / Wagstaff), or tibial (Tillaux-Chaput) insertion.

2. With shortening, without Volkmann's (AO/OTA 44C3.2) 

With shortening, without Volkmann's (AO/OTA 44C3.2)

With shortening, without Volkmann's (AO/OTA 44C3.2)

If there is a medial injury (deltoid rupture or malleolar fracture) and a proximal fibular injury, with significant shortening, but no Volkmann's fragment, this is classified as an AO/OTA 44C3.2 fracture.

The anterior and interosseous syndesmotic ligaments are always disrupted. The anterior ligament may fail as a ligamentous rupture, or an avulsion fracture, of the anterior syndesmotic ligament, either at its fibular (Le Fort / Wagstaff), or tibial (Tillaux-Chaput) insertion.

3. With medial lesion, with Volkmann's lesion (AO/OTA 44C3.3) 

With medial lesion, with Volkmann's lesion (AO/OTA 44C3.3)

With medial lesion, with Volkmann's lesion (AO/OTA 44C3.3)

If there is a medial and posterior malleolar fracture, and a proximal fibular injury, this is classified as an AO/OTA 44C3.3 fracture.

The anterior and interosseous syndesmotic ligaments are always disrupted. The anterior ligament may fail as a ligamentous rupture, or an avulsion fracture, of the anterior syndesmotic ligament, either at its fibular (Le Fort / Wagstaff), or tibial (Tillaux-Chaput) insertion.